Ans. 1. Aged care services and interdisciplinary care
The individuals equal or above the age of 60 years are termed as “Elderly” who comprise of the fastest growing category amongst the population of the world (WHO, 2014). Ageing is the result of changes in the biophysical processes that occur at a cellular level. Systematic nursing interventions based on elderly individuals’ nursing care needs lead to the notion of “independence”, which may be regarded as the empowerment of persons’ functional capacity on reducing their incapacities and raising their self-determination for a better management of their health processes. Care to patients with wounds includes from bio-physiological to intense subject matters, and ought to be given in a complete way, which is conceivable through systematization of nursing care (Corrêa, 2017).
There are five concepts associated in old age care which comprises of activities of daily living (ADL) associated with personal care, second ADL’s such as eating, drinking and toileting, third of mental functions, fourth of communication and fifth of support and relationships.
Concepts of self care and communication can be used as predictors of needs of nursing care after the individual’s responses have been analyzed based on their self care behaviours. The individuals showing signs of inability of water intake or in understanding spoken or written instructions unable to fall under the directives of universal self care and need support and management by specialized nursing interventions at the supportive-educational level. For e.g. Sarah being a patient of dementia required special care and support unlike the requirements of Alex who could be cared for by self care directives too. Sarah could be treated by the model of Therapeutic Self Care Deficit (Moderate)” level of nursing care needs i.e., when the individuals who cannot perform tasks independently and have to be assisted by the nursing care system like guiding others and giving support physically or psychologically, provided over a period of time as the person may have needs beyond his or her capacity (Goes, 2020).
The same is true of people with the highest education levels because literacy helps people better and more effectively cope with their health/disease processes. Alex, a post graduate and a retired teacher could be guided in taking home care of his non healing ulcer also (Batas, 2019).
To increase the independence of Alex and Sarah in caring for their needs themselves at home many communities have set up family health teams integrated to provide health care at home for frail elderly patients like Sarah. To ensure that the aged patients can remain in their environment of choice short time referrals and easy access are very essentials (Moore, 2012). Communication between the health teams plays a key role in implementing best practice.
Ans.2a. and b.) Age related changes and Patient assessments
A gentle decrease in the general precision is seen with the start of the 60s that advances gradually. Impaired cognition occurring in the older age group is associated with a decline in the functional activities of daily living and an increased risk of mortality (Amarya, 2018; Leiknes, 2015). Ageing results in lower neurological functions as the brain gets reduced blood flow Sarah’s dementia status with worsening with age. Also hypercholesteremia and narrowing of blood vessels is often seen especially in the extremities leading to varicose venous ulcers as seen in Alex.
Ageing comprises of a downward pathway in accommodation (presbyopia), glare tolerance, attentional visual fields, adaptation and colour discrimination which affect reading, driving and balancing (Amarya, 2018).
Normal ageing is described by a reduction in bone and bulk and an expansion in adiposity (Villa-Forte A, 2014). Functional sarcopaenia or age-related musculoskeletal changes influence 7% of older over the age of 70 years, and the pace of weakening increments with time, influencing over 20% of the old by the age of 80. Skeletal muscle quality (power creating limit) additionally gets decreased with maturing relying on hereditary, dietary and, natural factors just as way of life decisions.
Several studies have shown that patients with leg ulcers have a poor quality of life compared to age matched controls. Systematic review of studies measuring quality of life of patients with leg ulcers showed a negative impact on several domains of quality of life. Pain was shown to be the major complaint compared to controls, with males experiencing greater pain intensity than female patients. Some studies reported restricted mobility and sleep disturbance due to pain. Leg ulcer patients often complain of itchiness, odour and leg swelling. A negative emotional impact on life with symptoms such as anger, depression, and social isolation was reported by 68% (Adeyi, 2009).
Ideal treatment of wounds requires assessment of successful wound/ulcer care,(by the utilization of aseptic methods) (Oliveira, 2016) yet additionally comprehensive treatment of the patient covering all the essential life exercises, e.g. diet, rest, physical action and individual cleanliness—just as medical services training for patients and their families (Pessanha, 2015). This was to be followed by pain management immediately and wound debridement and antibiotic medication (Jensen, 2018). Compression treatment is generally perceived as a key treatment for varicose ulcers, as it expands the pace of recuperating and lessens the pace of recurrence after compressed treatment and non-pressure treatment (Sood, 2014). The ideal dressing ought to guarantee impermeability to water and different liquids as well as advance a wet climate too (Stoica, 2020).
The third priority was antibiotic coverage to avoid Alex from contracting any systemic infection at the sight of ulcers.
Ans.3 a.) Age-related changes that impact on pharmacokinetics (Absorption, Distribution, Metabolism & Excretion)
As age builds, the elements of tissues and organs in the body steadily decrease. Pharmacokinetics is the investigation of the ingestion, dispersion, digestion, and discharge (ADME) of medications.
Medication disintegration is affected by the maturing of the gastrointestinal mucosa in the old and the abatement of gastric corrosive emission (25% - 20% decrease).
Because of a reduction in the measure of plasma proteins, an expansion of fat rate and lessening of fit tissues (skeletal muscle, liver, mind, kidney, and so forth), when a similar portion of medication is utilized in older and youngsters, it has an elevated level of free state and more noteworthy usefulness in the old.
There are no anomalous changes in liver capacity in the older, yet the action of medication digestion protein in the liver is diminished so the half-life of the medication is drawn out. Likewise, the age-related decrease of parenchymal cells in the liver and a decrease of liver blood stream influences the capacity of the liver to utilize drugs.
The kidney is the principle organ engaged with drug discharge. It is the most significant factor in creating toxic medication responses in the older.
Ans.3b). Adverse drug events
Changes associated with aging affect the pharmacokinetics of medications. Once taken, a medication must obtain therapeutic levels in the bloodstream to exert a clinical action.
Ans.3c). Uses of medication and their potential complications
Aspirin reduces the risk of heart disease, clot related stroke and blood flow problems when used daily. However, aspirin therapy stresses the lining of the stomach and can cause heartburn, gastroesophageal reflux disease, even bleeding. It is associated with an increased risk of upper gastrointestinal (GI) bleeding and clinically relevant symptoms such as dyspepsia and gastroesophageal reflux disease (GERD) (Nirwan, 2020) which Alex could face as he was suffering from GORD.
Perindopril is used to treat high blood pressure and heart failure and also given after a heart attack to reduce the risk of heart attacks and future strokes and improves survival.
Glyceryl trinitrate, or GTN, is prescribed for chest pain associated with angina. It can give rise to respiratory problems (chronic cough etc.)
Omeprazole reduces the amount of acid in the stomach and used for indigestion, heartburn or acid reflux. It can prevent or treat stomach ulcers. However, Omeprazole in patients with hypertension and ARD may lead to a significantly more pronounced antihypertensive effect (Dorofeeva, 2019). which should be contraindicated to Alex.
Providing long-lasting pain relief, Panadol Osteo uses in osteoarthritis and back pain(analgesics (pain relievers) and antipyretics (fever reducers). Panadol Osteo is contraindicated in patients showing hypersensitivity to aspirin and NSAIDS.
Ibuprofen an anti-inflammatory drug can lead to indigestion or reflux. Anti-inflammatories can aggravate high blood pressure. They are generally very safe for short term use (up to thirty days).
Biophysical changes in occurring in the elderly group consists of biological organization ranging from molecular to organismic to populations. They significantly affect patients' lives, as they bring about torment, stability, inability, psycho-passionate changes identified with confidence and mental self-view, social changes coming about because of hospitalizations and social withdrawal (Corrêa, 2017). Disabilities resulting from ageing are not always a consequence of diseases. Senility and senescence are two different processes with the former resulting from pathology and latter from normal ageing. As a nurse with previous experiences of treating geriatric patients I found that disabilities are a result of experiences encountered throughout life and they can be modified too. The main motivation is to supervise the health care of the individuals by analyzing aging as a continuous and an accessible care model which allows the elderly individuals and the family to monitor health at home always under the expert guidance of the healthcare professionals which enable efficient management of the chronic conditions e.g. In Alex, co-morbidities of hypertension, MI, arthritis and GORD could only be managed over a period of time with good homecare support. Patients with chronic ulcers need long term management as in most of the cases these ulcers are a result of venous thrombosis secondary to MI. They are varicose veins which over a period of stagnation and low exercise become ulcerative. They pose an economic burden as well as long term treatment and frequent recurrence (Harding, 2015). Patients suffering from such ulcerative lesions report of a negative impact on daily aspects of their lives which can potentially lead to anxiety, depression and a psychosocial impact especially in the elderly. They are associated with foul odour, pain and exudates which can lead to immobility and disturbance in sleep patterns (Thomas Hess, 2010). Alex already burdened by his disease was further stressed with his wife care which was wholly on him. I feel this could be particularly very demanding for Alex physically as well as psychosocially. Optimul healing of wounds could be achieved only via holistic treatment of the patient covering all life’s basic activities like sleep, diet, physical activities and sanitization. Patient education is a must to make them aware of their importance of their health in order to avoid further complications, especially with respect to chronic wounds. We as health professionals should aim to empower the geriatric individuals with their relatives for optimal self care (Batas, 2019). Glaziou et al caution that in spite of the fact that observing patients' clinical advancement is a fundamental and significant part of care for constant ailment, it can too effortlessly turn into a custom with the possibility to delude clinicians, contribute little to the patients' comprehension of their ailment, and burn through everybody's time and resources (Glasziou, 2005).
Telecommunication use can also effectively increase the accessibility to healthcare treatment (e-health), which would lead to a reduction in the costs as well as improve self-care. When treating patients with chronic wounds need regular healthcare education.
In cases as of Mental disabilities, patience and home care assistance are of primary concern. Psychosocial ageing, considered as a phenomenon which comes along with biological ageing. Changes that happen with age in the functioning of individual organs influence the temperament, mentality, state of being, social movement and physical activity of the elderly. These lead to the main fear in the elderly characterized as the fundamental dread: dependence, loss of nobility and loneliness (Ferracioli, 2018). Cases like that of Sarah suffering from dementia require full home assistance by the nursing professionals more so in cases where the spouse is also suffering from co-morbidities. In cases especially where children are not living with the parents and the geriatric patients are unwell, it can impact them emotionally and socially as well leading to solitude, depression and worsening of dementia. With the advent of community health programs I found Alex could be aided in looking after Sarah with regular assistance and home care aid which was not there in years of my experience in treating the elderly. Often treatment of the elderly becomes challenging to the nursing professionals too but seeing Alex look after Sarah gave a boost to our profession and enabled us to provide our services with deeper understanding and compassion towards of patients. Care to injured patients should encompass holistic treatment including the bio-physiological and emotional factors that is only conceivable through the systematization of nursing care (Corrêa, 2017).
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